Healthcare Provider Details

I. General information

NPI: 1275793770
Provider Name (Legal Business Name): WENDY ELLIS GAYLORD LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2346 BROADWAY ST SUITE 3
BOULDER CO
80304-4107
US

IV. Provider business mailing address

5052 N FOOTHILLS HWY
BOULDER CO
80302-9363
US

V. Phone/Fax

Practice location:
  • Phone: 720-357-4448
  • Fax:
Mailing address:
  • Phone: 720-357-4448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR051672-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number943
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier02399273
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: